Explain the presacral surgical approach to the lumbosacral junction and its rationale

With the patient in the prone position, a small incision is made lateral to the coccyx. A blunt trocar is inserted under biplanar fluoroscopic guidance and advanced into the presacral space while maintaining contact with the anterior surface of the sacrum. A midline position is maintained and a guide pin is inserted into the sacrum at the S1-S2 level and advanced across the L5-S1 disc space into the L5 vertebral body. A series of dilators are used to create an intraosseous working channel. Using specialized instruments, the disc material is removed and the disc prepared for fusion. Finally an axial rod (AxiaLIF, TranSI, Wilmington, NC) is inserted to stabilize the disc space, and bone graft material is injected.

The presacral approach is intended to provide an option for minimally invasive surgical access to the lumbosacral junction that does not require mobilization of the iliac vessels, limits muscle dissection, and avoids disruption of the autonomic nerves overlying the lumbosacral disc. Potential complications associated with this approach include wound dehiscence, infection, bowel injury, vascular injury, and pseudarthrosis. See Figure 70-5.

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